Maternal-infant relationship quality and risk of obesity at age 5.5 years in a national US cohort

Anderson et al. BMC Pediatrics 2014, 14:54
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RESEARCH ARTICLE

Open Access

Maternal-infant relationship quality and risk of
obesity at age 5.5 years in a national US cohort
Sarah E Anderson1*, Stanley Lemeshow2 and Robert C Whitaker3

Abstract
Background: Poor quality relationships between mothers and toddlers have been associated with higher risk for
childhood obesity, but few prospective studies of obesity have assessed maternal-child relationship quality in
infancy. In addition it is not known whether the increased risk is associated with the mother’s or the child’s
contribution to the relationship quality.
Methods: We analyzed data (n = 5650) from the Early Childhood Longitudinal Study, Birth Cohort, a national study
of U.S. children born in 2001 and followed until they entered kindergarten. At 9 months of age, the Nursing Child
Assessment Teaching Scale (NCATS) was used to assess the quality of observed playtime interactions between
mothers and infants, yielding separate scores for maternal and infant behaviors. Obesity (BMI ≥95th percentile) at
age 5.5 years was based on measured weight and height.
Results: The prevalence (95% confidence interval) of obesity at 5.5 years of age was higher among children in the
lowest quartile of maternal NCATS score (20.2% [95% CI: 17.2%, 23.2%]) than in the highest quartile (13.9% [11.3%,
16.5%]), but maternal NCATS score was not significantly associated with obesity after adjustment for race/ethnicity,
maternal education and household income. The prevalence of obesity at 5.5 years of age was similar among
children in the lowest quartile of infant NCATS score (17.4% [14.4%, 20.3%]) and in the highest quartile (17.6%
14.4%, 20.8%]), and was not changed with covariate adjustment.
Conclusions: Maternal-infant relationship quality, assessed by direct observation at 9 months of age in a national
sample, was not associated with an increased risk of obesity at age 5.5 years after controlling for sociodemographic
characteristics.
Keywords: Mother-child relationship, Parent–child interactions, Maternal sensitivity, Obesity, Cohort studies, Infancy,
Parenting, Body mass index

Background
Whether the quality of parent–child interactions is related to children’s obesity risk is not a new research
question [1,2], but systematic investigation of this topic,
particularly in population studies, has been limited [3].
We have provided evidence from two national studies
that maternal-child interactions characterized by an insecure pattern of attachment and low levels of maternal
sensitivity are associated with higher risk for obesity [4,5].
Others have also identified low levels of maternal warmth
and sensitivity as risk factors for obesity [6-9]. Maternal
sensitivity is one contributor to the quality of maternal* Correspondence:
1
Division of Epidemiology, The Ohio State University College of Public
Health, 336 Cunz Hall, 1841 Neil Avenue, Columbus, Ohio 43210, USA
Full list of author information is available at the end of the article

child relationships and increases the likelihood that a child
will develop a secure pattern of attachment [10,11].
Evolving with time, the maternal-child relationship is
shaped by the behavior and responses of both the
mother and the child [12-14]. Just as parenting behavior
can affect children, children’s behavior also influences
parenting [13,15]. The construct of mutually responsive
orientation has been developed to describe the positive,
reciprocal, and synchronous interactions that are characteristic of high-quality parent-child relationships [16].
There is innate variability in infant reactivity, predictability, responsiveness, mood, and activity level [17,18], and
the contributions of children’s temperamental attributes
to early childhood obesity prevention are being examined [19]. The need to include dyadic conceptualizations

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Anderson et al. BMC Pediatrics 2014, 14:54
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and measurements of parent-child interaction in obesity
research has been recognized [3], but there have been
few studies of childhood obesity that have examined the
contributions of both the parent and the child to parentchild relationship quality.
Infancy is an important time period to study the quality of maternal-child interactions relative to obesity risk
because it is during this time period that the limbic areas
of the brain governing stress response and emotion
regulation are rapidly developing in relationship to the
social environment [20]. These areas of the brain are
also involved in regulation of energy balance which can
be disrupted by an exaggerated stress response [21]. In
two longitudinal studies we have shown that those
toddlers who have poorer quality relationships with their
mothers were at greater risk of later obesity [4,5]. In
the current study, we used a large national sample to
determine whether poorer quality interactions between
mothers and infants increased the risk of childhood
obesity, and to examine whether any increased risk was
due to the behaviors of the infants, the mothers, or to
both participants in the dyadic interaction.

Methods

Early Childhood Longitudinal Study, Birth Cohort (ECLS-B)

We analyzed data collected in the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B), a study conducted by
the National Center for Education Statistics (NCES) [22].
The NCES ethics review board approved the data collection, and parents provided written informed consent.
Analyses reported here were conducted at The Ohio
State University under a restricted-use data agreement.
This agreement requires that we report unweighted
sample sizes by rounding to the nearest 50.
The ECLS-B was designed to be representative of children born in the United States in 2001. The complex
sampling design of the study has been previously described [22], and is briefly summarized here. A clustered
list-frame design was used to select a probability sample
of 14000 U.S. births in 2001. Children were excluded
from the study if they were born to mothers under
15 years of age or if, before 9 months of age, infants had
died or were adopted. When the children were 9 months
of age, the final study cohort of 10700 was formed, and
additional assessments took place when children were
24 months old (n = 9850) and approximately 4.5 years
old (n = 8900). For budgetary reasons, an 85% random
subsample (n = 7700) was selected for inclusion in the follow up at age 5.5 years, and 6950 children were assessed at
that time [23]. Data were collected during visits to the children’s homes, and included a computer-assisted personal
interview with the child’s mother (or, in a small number of
cases, the father or other guardian), and direct measurements and observations of children and mothers.

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Maternal-infant interaction

During the 9-month home visits, the Nursing Child

Assessment Teaching Scale (NCATS) was used to assess interactions between mothers and infants [24].
The NCATS is a standardized tool for assessing interactions between young children (0 to 36 months of
age) and their parent or caregiver, and it has been used
widely in research and clinical settings [14,25]. The
NCATS is scored for 73 aspects of mother-infant interaction (50 items for the maternal score, 23 for the infant score). Higher scores indicate a higher quality
(more adaptive and mutually responsive) pattern of
interaction between mother and child. The maternal
NCATS items assess maternal sensitivity to infant’s
cues, response to infant’s distress, and fostering of infant’s social-emotional and cognitive growth [14]. The
infant NCATS items assess the infant’s clarity of cues
and infant’s responsiveness to the mother. To conduct
the NCATS, mothers were shown a list of “activities”
ordered by difficulty and asked to teach their infant the
first activity on the list that he/she was not yet able to
do; for example, “reach for a rattle, scribble on a piece
of paper, stack 2 blocks on top of each other” [14]. The
ECLS-B field interviewers videotaped the interaction
between mother and infant, and the videotapes were
coded in a central location by trained coders who had
demonstrated reliable coding [25]. The internal consistency
(Cronbach’s alpha) of the maternal and infant NCATS
scores in ECLS-B were, respectively, 0.68 and 0.62 [25].
Obesity

At 5.5 years of age, children’s height and weight were
measured in the home using a standardized protocol.
Height was measured with a portable stadiometer and
weight was measured with a digital scale (both instruments from Seca [Hanover, MD]) while children were
wearing light clothing and no shoes [26]. Measurements
were taken three times, and the average value of the two

closest measurements was used to calculate the child’s
body mass index (BMI = kg/m2). We categorized children as obese if they had a sex-specific BMI-for-age at
or above the 95th percentile of the U.S. Centers for Disease Control and Prevention growth reference [27].
Covariates

Additional variables were considered for inclusion in our
analyses based on their established relationship with
obesity and possible relationship with maternal-infant
interaction. Birth weight was obtained from birth certificate records. At the 9-month interview with the mother,
each child’s age, gender, and race/ethnicity were obtained, and mothers were asked whether they had ever
breastfed the child, the age of the child at weaning, and
when solid foods were introduced [28]. Data were not


Anderson et al. BMC Pediatrics 2014, 14:54
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available to determine the practice or duration of exclusive breastfeeding. Mothers were classified as smokers if
they reported smoking cigarettes at the time of the 9month interview. Maternal BMI was calculated from
measured weight and self-reported height. We used two
variables, maternal education and household income-topoverty ratio, to estimate socioeconomic status (SES);
both were derived from responses to the 9-month interview. The income-to-poverty ratio was calculated relative to 2002 U.S. poverty levels [29].

Statistical analysis

Our analyses included the 5650 children who had data
available on NCATS at 9 months and measured height
and weight at 5.5 years. Of the 6950 children in ECLS-B
that were assessed at 5.5 years, we excluded 1350 children—1200 children who did not participate in the
NCATS assessment or whose videotape was not codable
and 150 children who were missing height or weight at

5.5 years. We applied ECLS-B sampling weights, which include adjustments for disproportionate sampling, undercoverage of the target population, and nonresponse at each
wave of data collection [30]. Variance estimates that account for the complex sample design were calculated using
Jackknife replicate weights [23,31] as implemented in the
survey procedures in SAS [32].
We created quartiles for the maternal and infant
NCATS scores. We examined covariates relative to the
prevalence of being obese at 5.5 years, in the lowest
quartile of maternal NCATS score, and in the lowest
quartile of infant NCATS score, and we used the RaoScott design-corrected Χ2 to test for group differences.
We used logistic regression [33] to estimate odds ratios
(ORs) and 95% confidence intervals (CIs) for childhood
obesity comparing increasing quartiles of the maternal
NCATS score and infant NCATS score to the lowest
quartile. We assessed the functional form of the association between childhood obesity and NCATS scores
using LOWESS smoothed scatterplots and the method
of fractional polynomials [34]. Both maternal and infant
NCATS scores were linear in the logit. We used logistic
regression [33] to estimate the association of unit differences in maternal NCATS score or infant NCATS score,
each modeled as a continuous variable, with odds for
childhood obesity. Our analyses were conducted in steps;
first unadjusted models were estimated, then models
were adjusted for increasing numbers of covariates: 1)
child level covariates (age, sex, birth weight, infant
feeding), 2) maternal covariates (BMI and smoking)
and 3) all covariates including race/ethnicity and SES.
We present analyses with and without adjustment for
SES because these variables may be confounding variables or may be part of a causal chain or pathway to

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obesity that also involves the quality of the maternalinfant relationship [4,35,36].

Results
When compared to the analytic sample (n = 5650), children
who were excluded for missing information (n = 1350) did
not differ by sex (P = .26) but were more likely to have
mothers who had not finished high school (24.9% vs. 17.7%,
P < .001), to have an income-to-poverty ratio below 1.85
(54.7% vs. 46.5%, P = .01), and to be of Hispanic ethnicity
(29.8% vs. 22.9%, P = .002). The prevalence of obesity at
5.5 years was 17.3% in the analytic sample and 19.4%
among the 1200 children missing the NCATS (P = .25).
Maternal NCATS scores ranged from 15 to 49 with a
mean (standard deviation [SD]) of 34.7 (4.5) and 25th,
50th, and 75th percentile values of 31.7, 34.8, and 37.8,
respectively. Infant NCATS scores ranged from 7 to 23
with mean (SD) of 15.5 (2.7) and 25th, 50th, and 75th
percentile values of 13.7, 15.7, and 17.0. The correlation
of maternal to infant scores was r = .24. All of the maternal
and child characteristics we examined, except for child sex
and age at introduction of solid foods, were statistically
significantly related to maternal NCATS score and to obesity at 5.5 years (Table 1). However, none of these same
characteristics were associated with infant NCATS score
(Table 1).
The prevalence of obesity at age 5.5 years was 20.2%
(95% CI: 17.2% – 23.2%) among those children whose
mother was in the lowest quartile of the maternal NCATS
score compared to 13.9% (95% CI: 11.3% – 16.5%) among
those whose mother was in the highest quartile. The prevalence of obesity was intermediate for the second and third
quartiles of the maternal NCATS score, and the trend

was statistically significant (Table 2). When modeled as a
continuous variable in logistic regression, lower maternal
NCATS score was related to higher odds of obesity at
5.5 years (P = .0012). Based on this unadjusted model, each
5 unit (approximately 1 SD) difference in maternal NCATS
score at 9 months was associated with odds of obesity at
5.5 years that were 1.21 (95% CI: 1.08 – 1.36) times those
of infants with mothers who had higher (worse) NCATS
scores (Table 3). This estimate was little changed with adjustment for child age, sex, birth weight, and infant feeding
variables, or with additional adjustment for maternal weight
and smoking status (Table 3). However, with adjustment
for all covariates the odds of obesity at 5.5 years associated
with a 5 unit difference in maternal NCATS score was attenuated to 1.09 and was not statistically significant (95%
CI: 0.95 – 1.24). This pattern of results was not changed by
adjustment for infant NCATS score, and we observed no
evidence that infant NCATS score modified associations
between maternal NCATS score and obesity at 5.5 years
(P-value for interaction = .99).


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Table 1 Participant characteristics in relation to lowest quartile maternal and infant NCATS score and child obesity
Na (%)

Lowest quartile maternal NCATS
% (95% CI)

% (95% CI)

% (95% CI)

5650

23.3 (21.3 – 25.4)

23.1 (21.7 – 24.5)

17.3 (15.9 – 18.7)

2800 (49.3)

22.6 (20.2 – 25.1)

22.3 (20.5 – 24.1)

16.3 (14.2 – 18.3)

2850 (50.7)

24.0 (21.6 – 26.4)

23.9 (21.6 – 26.2)

18.4 (16.2 – 20.5)

.69

.66

.17

550 (1.2)

29.4 (24.9 – 34.0)

31.1 (26.2 – 36.1)

8.8 (6.0 – 11.7)

1500 – <2500 grams

850 (6.1)

26.4 (22.5 – 30.3)

27.6 (23.7 – 31.6)

12.3 (9.3 – 15.2)

2500 – < 3000 grams

1050 (16.8)

27.0 (22.7 – 31.2)

26.0 (21.6 – 30.3)

13.2 (10.3 – 16.1)

Total

Lowest quartile infant NCATS

Obesity at 5.5 yc

Sex
Female
Male
P-valueb
Birth weight
<1500 grams

3000 – < 3500 grams

1650 (37.9)

23.4 (20.3 – 26.5)

23.1 (20.7 – 25.5)

16.2 (13.7 – 18.7)

3500 – < 4000 grams

1150 (28.1)

21.7 (18.4 – 24.9)

20.0 (17.3 – 22.7)

18.8 (16.1 – 21.6)

350 (9.9)

19.1 (13.3 – 24.9)

23.2 (18.2 – 28.1)

28.9 (23.4 – 34.4)

.009

.15

<.0001

≥ 4000 grams
P-valueb
Duration of breastfeeding
≥6 months

700 (13.5)

17.3 (13.0 – 21.6)

19.5 (15.3 – 23.6)

13.1 (10.0 – 16.2)

2 to <6 months

1350 (23.3)

25.0 (21.5 – 28.4)

24.8 (21.6 – 28.0)

17.3 (14.3 – 20.3)

<2 months

1800 (33.8)

21.0 (18.1 – 23.9)

22.9 (20.6 – 25.2)

15.8 (13.5 – 18.1)

1700 (29.5)

27.6 (24.1 – 31.1)

23.8 (21.0 – 26.6)

21.0 (17.7 – 24.4)

<.0001

.69

.005

Never
P-valueb
Age introduced solid foods
≥6 months

1800 (26.2)

23.9 (19.8 – 28.0)

24.6 (21.5 – 27.7)

17.0 (14.7 – 19.3)

4-5 months

2700 (50.4)

22.6 (20.0 – 25.1)

22.8 (20.6 – 24.9)

16.2 (14.0 – 18.4)

0-3 months

1150 (23.4)

24.3 (20.5 – 28.2)

22.1 (18.9 – 25.4)

20.1 (17.0 – 23.1)

.14

.77

.09

P-value

b

Maternal BMId
300 (4.5)

19.2 (12.4 – 26.0)

17.8 (12.6 – 23.0)

10.1 (4.7 – 15.4)

2250 (39.3)

21.8 (18.5 – 25.0)

23.0 (20.3 – 25.6)

9.3 (7.3 – 11.2)

25 - <30 kg/m

1400 (28.1)

23.8 (20.5 – 27.1)

20.9 (17.7 – 24.1)

18.0 (15.5 – 20.4)

≥30 kg/m2

1550 (28.1)

24.6 (21.4 – 27.7)

25.8 (22.8 – 28.8)

28.9 (25.7 – 32.1)

.002

.40

<.0001

<18.5 kg/m2
18.5 - <25 kg/m2
2

P-value

b

Maternal smoking status
Nonsmoker

4600 (81.7)

22.4 (20.3 – 24.4)

23.0 (21.4 – 24.6)

16.6 (15.0 – 18.1)

Smoker

1050 (18.3)

27.7 (23.1 – 32.2)

23.8 (19.7 – 27.8)

20.9 (17.2 – 24.6)

<.0001

.90

.02

P-value

b

Racial-ethnic group
White, non-Hispanic

2350 (55.1)

18.4 (15.7 – 21.1)

23.1 (20.9 – 25.4)

12.9 (11.2 – 14.5)

Black, non-Hispanic

950 (15.5)

24.3 (20.5 – 28.2)

20.4 (17.0 – 23.8)

21.2 (17.3 – 25.1)

Hispanic, any race

1000 (22.9)

34.4 (29.3 – 39.5)

25.2 (22.3 – 28.1)

24.1 (19.8 – 28.3)

Other race, non-Hispanic

1300 (6.4)

24.1 (19.4 – 28.8)

22.0 (17.8 – 26.2)

22.3 (16.9 – 27.6)

<.0001

.68

<.0001

P-value

b


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Table 1 Participant characteristics in relation to lowest quartile maternal and infant NCATS score and child obesity
(Continued)
Na (%)

Lowest quartile maternal NCATS

Lowest quartile infant NCATS

Obesity at 5.5 yc

% (95% CI)

% (95% CI)

% (95% CI)

Maternal education
< High school

950 (17.7)

38.4 (33.1 – 43.8)

26.6 (22.8 – 30.5)

21.2 (17.6 – 24.9)

High school degree or GED

1450 (27.7)

29.3 (25.8 – 32.7)

23.2 (20.6 – 25.8)

20.6 (17.2 – 24.0)

Some college

1600 (29.1)

18.0 (15.1 – 21.0)

23.6 (20.8 – 26.4)

17.4 (14.9 – 20.0)

College graduate

1650 (25.4)

12.3 (9.9 – 14.7)

20.0 (17.4 – 22.6)

11.1 (8.8 – 13.3)

<.0001

.53

<.0001

P-value

b

Household income/poverty ratio
< 0.50

650 (10.3)

38.3 (32.3 – 44.3)

23.9 (18.8 – 29.0)

20.8 (17.1 – 24.6)

0.50 to 0.99

700 (12.7)

29.9 (24.6 – 35.3)

25.6 (21.1 – 30.1)

22.6 (17.5 – 27.6)

1.00 to 1.85

1300 (23.5)

31.3 (26.9 – 35.7)

26.4 (23.0 – 29.8)

20.9 (17.8 – 24.0)

1.86 to 3.00

1550 (28.0)

17.6 (14.3 – 20.9)

21.0 (18.2 – 23.8)

14.8 (11.9 – 17.8)

1450 (25.4)

13.0 (10.6 – 15.3)

20.8 (17.3 – 24.4)

12.8 (10.2 – 15.4)

<.0001

.07

<.0001

>3.00
P-valueb

Restricted to children with information on NCATS at 9 months and weight-status at 5.5 years.
a
N is unweighted and rounded to the nearest 50. Percents are weighted and 95% confidence intervals account for survey design. Percentages may not total 100%
due to rounding.
b
P-value from Rao-Scott design-adjusted Χ2 tests.
c
BMI-for-age ≥95th percentile at age 5.5 years.
d
Maternal BMI from reported height and measured weight at 9 month assessment. If maternal height was available but weight at the 9 month assessment was
missing (n = 1000) then measured weight from the first available assessment was substituted [24 months (n = 700), 4.5 years (n = 250), 5.5 years (n = 50)].
Information missing for 150 individuals for maternal BMI, <100 individuals for breast feeding duration, and <50 individuals for birth weight, age introduced solid
foods, maternal smoking status, and maternal education.

We observed no evidence of an association between infant NCATS scores and obesity at age 5.5 years irrespective
of modeling approach. The prevalence (95% CI) of obesity
was 17.4% (95% CI: 14.4% – 20.3%) in the lowest quartile of
the infant NCATS and 17.6% (95% CI: 14.4% – 20.8%) in

the highest quartile (Table 2). Modeled as a continuous
variable in logistic regression analyses, lower scores on the
infant NCATS were not associated with higher risk for

obesity with or without covariate adjustment (P-values
between .34 and .42).
Twenty of the items in the maternal NCATS score and
twelve in the infant NCATS score are designated as “contingency items” because they are coded for behaviors made
by one participant in the interaction (the mother or the
child) in response to the other [14]. Consistent with what
we observed for the full scores, the maternal contingency

Table 2 Quartiles of maternal and infant NCATS scores at 9 months and obesity at 5.5 years
NCATS score range
(min – max)

N (%)a

Obesity prevalence at
5.5 years (95% CI)

P trendb

Unadjusted OR (95% CI)
for obesity at 5.5 years

Q1 (low)

15.0 – 31.7

1400 (23.3)

20.2 (17.2 - 23.2)

.0012

1.57 (1.17 - 2.10)

Q2

31.8 – 34.7

1400 (24.6)

19.6 (16.5 - 22.6)

1.51 (1.11 - 2.05)

Q3

34.8 – 37.8

1450 (25.8)

16.1 (13.5 - 18.7)

1.19 (0.89 - 1.60)

Q4 (high)

37.9 – 49.0

1400 (26.3)

13.9 (11.3 - 16.5)

1.0 (referent)

Q1 (low)

7.0 – 13.7

1450 (23.1)

17.4 (14.4 - 20.3)

Q2

13.8 – 15.7

1450 (25.1)

20.0 (17.2 - 22.7)

1.17 (0.90 - 1.53)

Q3

15.8 – 17.0

1550 (28.5)

14.8 (12.5 - 17.1)

0.81 (0.61 - 1.09)

Q4 (high)

17.1 – 23.0

1200 (23.3)

17.6 (14.4 - 20.8)

1.0 (referent)

Maternal

Infant
.42

0.99 (0.74 - 1.32)

Restricted to children with information on NCATS at 9 months and weight-status at 5.5 years.
a
N is unweighted and rounded to the nearest 50. Percents are weighted and 95% confidence intervals account for survey design. Percentages may not total 100%
due to rounding.
b
P-value from logistic regression models with NCATS score as a continuous variable; P-values for these trends were similar when quartiles were modeled.

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Table 3 Logistic regression models of association between maternal NCATS score and obesity at age 5.5 years
N

Estimate

SE

P-valuea

OR (95% CI) for obesity associated with a 5
unit decrease in maternal NCATS scoreb

5650

0.038

0.012

.0012

1.21 (1.08 - 1.36)c

Adjusted for child covariates

5500

0.039

0.013

.0017

1.22 (1.08 - 1.38)

Adjusted for child and maternal covariatese

5450

0.033

0.013

.01

1.18 (1.04 - 1.33)

5450

0.016

0.014

.23

1.09 (0.95 - 1.24)

Model
Unadjusted
d

f

Adjusted for all covariates
a

P from logistic regression modeling maternal NCATS as a continuous variable.
b
Difference in maternal NCATS score of 5 units is approximately 1 SD.
c
Results of unadjusted model were unchanged with exclusion of the 200 children who were missing information on ≥1 covariate.
d
Covariates = age, gender, birth weight, duration of breast feeding, age when solid food introduced.
e
Covariates = age, gender, birth weight, duration of breast feeding, age when solid food introduced, maternal BMI, maternal smoking.
f
Covariates = age, gender, birth weight, duration of breast feeding, age when solid food introduced, maternal BMI, maternal smoking, race/ethnicity, maternal
education, income-to-poverty ratio.

score was associated with higher risk for obesity at age
5.5 years in models that were not adjusted for SES, but not
in models that adjusted for SES. The infant contingency
score was not associated with obesity in either adjusted or
unadjusted models.

Discussion

We sought to assess the extent to which maternal and
infant components of observed interactions between
9-month-old infants and their mothers were associated
with obesity risk at 5.5 years of age in a large national
cohort study. After controlling for SES, lower scores on
the maternal component of the NCATS, which assesses
maternal sensitivity, responsiveness, and fostering of infant emotional and cognitive growth, were not associated
with an increased risk for obesity at 5.5 years of age.
Our results showed no evidence that the infant’s contribution to the maternal-infant interaction affected the
risk of obesity, nor did infant behavior modify the relationship between maternal behavior and children’s obesity risk.
Using observations of non-feeding interactions between
mothers and infants, our goal was to examine separately
the contributions of the infants’ and the mothers’ behaviors
to the risk of childhood obesity. Prior research suggests that
children’s self-regulation capacity is likely to be an important factor in the development of obesity [37-39]. Selfregulation, including emotion regulation, appears to be
optimized by a parent–child relationship that has a mutually responsive orientation, meaning that interactions between parent and child are cooperative, coordinated, and
harmonious, and involve the display of positive emotion
[16,40,41]. Direct observation is the best method to assess
whether the maternal-child relationship is mutually responsive [42]. The child’s behaviors, especially the child’s responsiveness to the mother, reflects more than the child’s
temperament [43], and the importance of studying children’s contribution to the quality of maternal-child interaction in the context of obesity has been recognized [3].
Although the NCATS was not designed to assess mutually

responsive orientation per se, it is based on direct observation and consists of separately coded behaviors for infants
and mothers, including a subset of contingency items
that assess the infant’s and mother’s responsiveness to one
another.
Only a single study has examined the relationship
between NCATS scores and childhood obesity [44].
Washington and colleagues recruited 200 low-income
Mexican-American toddlers and their mothers at a WIC

clinic in one Texas city. Half of the children were obese
(BMI ≥95th percentile) and half were normal weight
(BMI <85th percentile) and the NCATS was administered at two time points separated by six months [44].
Overall, there was no evidence that obese children had
lower scores on the maternal or child NCATS, and some
suggestion of higher scores for mothers of obese compared to normal weight toddlers [44]. However it is difficult to compare their findings to ours because of the
small size and low sociodemographic heterogeneity of
their sample.
We are not aware of additional studies of obesity and
parent–child interaction that have directly assessed
parent and child contributions to the quality of the relationship, but two studies have examined whether the relationship between maternal sensitivity and childhood
obesity was modified by child temperament as reported
by the parent. In a longitudinal analysis of 900 children
studied between infancy and grade 6, Wu and colleagues
found no relationship between infant temperament and
the risk of being overweight or obese at school age
(grades 1–6), but they did find that lower maternal sensitivity during infancy was associated with later weight
status [9]. Although we did not find such a relationship,
our study had a more socioeconomically diverse sample
and involved a different measure of maternal interaction
with the infant. Other prospective studies have shown
that lower maternal warmth and sensitivity in interaction with toddlers [4,5], school-age children [6,8], and
adolescents [7] is associated with a risk of later obesity.
In a cross-sectional study of treatment-seeking obese


Anderson et al. BMC Pediatrics 2014, 14:54
/>
youth (ages 8–16 years) in comparison to nonoverweight controls, obesity was associated with low
maternal warmth but only among children rated as

temperamentally difficult [45].
Limitations

Some ECLS-B participants were lost-to-follow-up or did
not have NCATS data in infancy. This could have biased
our findings and the direction of the bias is not possible
to know. We controlled for infant birth weight and feeding, but we had no information on infant sleep quality
or quantity. We did not have data on the interactions
between fathers and infants; the quality of such interactions between fathers and infants may have affected children’s risk for obesity or modified how maternal-infant
interaction was related to childhood obesity.
Although the NCATS is based on observed maternalinfant interaction and yields separate scores for maternal
and infant behaviors, the measure has limitations. The
internal consistency (Cronbach’s alpha) of the NCATS
scores in ECLS-B were between 0.6 and 0.7, which is
lower than the reliability values reported by others [14].
Our data were based on a single, brief interaction, which
may not have been a typical one. Others have argued
that the NCATS is more sensitive to cognitive than to
affective components of mother-child interaction and
contains items that may reflect cultural biases about parenting [46,47]. It is possible that the NCATS, as implemented in this study, did not adequately measure the
emotional quality of the maternal interaction with the
child, and this could be one reason we did not observe a
stronger association between the quality of maternal
interaction and children’s obesity risk.
In our study, maternal NCATS scores were related to
race/ethnicity and sociodemographic characteristics, as
had been seen in other studies [14]. In our analyses, we
found that lower maternal NCATS scores were associated with obesity in models adjusted for the infant’s age,
gender, birth weight, and feeding practices and the
mother’s BMI and smoking status, but the association

between maternal NCATS score and obesity was attenuated and no longer statistically significant with adjustment
for race/ethnicity and sociodemographic characteristics—a
pattern similar to what we have found previously [4]. We
cannot distinguish with an observational study whether
these results are due to a causal pathway going from these
sociodemographic factors to the quality of the maternalchild relationship to obesity, or to confounding.

Conclusions
In this longitudinal study of a large national sample, the
risk of obesity at 5.5 years of age was not associated with
maternal-infant relationship quality. The lack of association was clearer for the infant contribution to

Page 7 of 8

relationship quality than for the maternal contribution,
which was significant before adjustment for SES. Our
findings leave open the possibility that low levels of maternal sensitivity may increase risk for childhood obesity
and suggest that further research focus on the mother’s
not the infant’s, contribution to the quality of maternalchild relationship. This approach would be consistent
with interventions that have demonstrated the potential
to increase parental sensitivity [48], and in so doing have
a beneficial impact on children’s weight [49].
Abbreviations
BMI: Body mass index; CI: Confidence interval; ECLS-B: Early Childhood
Longitudinal Study-Birth Cohort; NCATS: Nursing Child Assessment Teaching
Scale; OR: Odds ratio; SD: Standard deviation; SES: Socioeconomic status.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
SA and RW conceived the study and acquired funding. SA analyzed the data

and drafted the manuscript. All authors were involved in interpretation of
the data, critically revised the manuscript for important intellectual content,
and read and approved the final manuscript.
Acknowledgements
This work was supported by grant R01DK088913 from the National Institutes
of Health. All data used in this study were collected by the National Center
for Education Statistics, within the Institute of Education Sciences of the US
Department of Education. A license agreement is in place with The Ohio
State University for analysis of restricted-use data from this study. The
manuscript was cleared by the National Center for Education Statistics Data
Security Office after disclosure review. Neither the sponsor nor the funder
was involved in the design or conduct of the analyses, interpretation of results,
preparation or approval of the manuscript, or decision to publish the study.
Author details
1
Division of Epidemiology, The Ohio State University College of Public
Health, 336 Cunz Hall, 1841 Neil Avenue, Columbus, Ohio 43210, USA.
2
Division of Biostatistics, The Ohio State University College of Public Health,
204 Cunz Hall, 1841 Neil Avenue, Columbus, Ohio 43210, USA. 3Departments
of Public Health and Pediatrics and Center for Obesity Research and
Education, Temple University, 1801 N Broad Street, Philadelphia, Pennsylvania
19122, USA.
Received: 11 December 2013 Accepted: 19 February 2014
Published: 24 February 2014
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doi:10.1186/1471-2431-14-54
Cite this article as: Anderson et al.: Maternal-infant relationship quality

and risk of obesity at age 5.5 years in a national US cohort. BMC
Pediatrics 2014 14:54.